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Keywords:

  • Aboriginal;
  • Indigenous;
  • social and emotional wellbeing;
  • programs;
  • evaluation

Abstract

  1. Top of page
  2. Abstract
  3. Identification and classification of studies
  4. Results
  5. Discussion
  6. References

Objective : To review the empirical evidence that exists to support the delivery of the range of psycho-social interventions that have been implemented to improve social and emotional wellbeing (SEWB) in Aboriginal and Torres Strait Islander individuals and communities.

Methods : A systematic review of the available literature, with relevant evaluations classified using the Maryland Scientific Methods Scale.

Results : Despite a substantial literature on topics relevant to SEWB being identified, only a small number of program evaluations have been published that meet the criteria for inclusion in a systematic review, making it impossible to articulate what might be considered evidence-based practice in this area. Examples of those programs with the strongest empirical support are outlined.

Conclusions : The results are discussed in terms of the need to develop key indicators of improvement in SEWB, such that more robust evidence about program outcomes can be gathered. The diversity of the identified programs further suggests the need to develop a broader and over-arching framework from which to approach low levels of SEWB, drawing on the concepts of ‘grief and loss’ and ‘healing’ and how high levels of social disadvantage have an impact on service utilisation and outcomes.

Implications : From a public health perspective, the pressing need to implement programs that have positive impacts on low levels of social and emotional well-being in Aboriginal and Torres Strait Islander communities in Australia seems clear.

The construct of Social and Emotional Wellbeing (SEWB) is used to refer to the idea that mental health is a state of wellbeing relating to a person's awareness of his or her ability to cope with everyday stressors, to work productively and to make positive contributions to the community.1 Personal wellbeing is understood as contingent upon social influences, such as the level of social support that is available or the context in which emotional states arise.2 In relation to mental health, personal wellbeing identifies the need to look at not only the presence of a diagnosable mental health disorder, but also the socio-historical factors, personal choice and values, language, culture, emotional affect, social control and social values that cause distress.3

In Australia, the term SEWB has, perhaps unsurprisingly, been most frequently used in relation to conceptualising mental health in Aboriginal and Torres Strait Islander communities. It is regarded as a culturally appropriate construct in that it reflects the holistic philosophy that many Aboriginal and Torres Strait Islander people have towards health4 and encapsulates the wide range of experiences that have the potential to adversely affect an individual's wellbeing. Many of these experiences are familiar to those who identify as from Aboriginal and Torres Strait Islander cultural backgrounds. They include: environmental deprivation; emotional, physical and sexual abuse; emotional and physical neglect; stress; social exclusion; grief and trauma; removal from family; substance abuse; family breakdowns; cultural disconnection; racism; discrimination; domestic violence; and social disadvantage.5 The Productivity Commission,6 in its most recent report, Overcoming Indigenous Disadvantage, considered the current status of three indicators of disadvantage that are directly associated with low levels of social and emotional wellbeing: substantiated child abuse and neglect; family and community violence; and imprisonment and juvenile detention. Their statistics suggest that progress in closing the gap in Indigenous and non-Indigenous disadvantage in each of these areas has been both uneven and slow. In relation to child abuse and neglect, for example, the substantiation rate for mandatory reports for Indigenous children increased from 15 to 37 per 1,000 children between 1999 and 2000, and 2009 and 2010, compared to an increase from four to five per 1,000 for non-Indigenous children (although it is not clear how much of this increase can be attributed to increased reporting and how much is due to an actual increase in child abuse and neglect). In relation to family violence, the proportion of Indigenous people who reported having experienced physical or threatened violence over the previous 12 months had not changed between 2002 and 2008. The national Indigenous juvenile detention rate increased from 318 per 100,000 juveniles in 2001 to 365 per 100,000 in 2009. Such statistics provide a strong rationale for identifying and implementing programs with the potential to bring about improvement in these key performance indicators.

In what remains one of the most comprehensive surveys of social and emotional wellbeing in Indigenous Australians, the 2004–2005 National Aboriginal and Torres Strait Islander Health Survey7 identified eight domains by which wellbeing could be measured. These were: psychological distress, impact of psychological distress, life stressors, discrimination, anger, removal from natural family, cultural identification and positive wellbeing. The results of the survey showed that more than one quarter (27%) of the sample of Aboriginal and Torres Strait Islander adults reported experiencing high levels of psychological distress; levels that were twice as high as those experienced by non-Indigenous Australians. Four in 10 people reported they had experienced, or knew someone who had experienced, the death of a family member or friend in the last year, nearly one-third (28%) reported serious illness or disability, and one-fifth (20%) reported alcohol-related issues. Life expectancy was seventeen years shorter than for non-Indigenous Australians and, despite poorer health, Aboriginal and Torres Strait Islander adults were unlikely to seek healthcare due to factors including, but not limited to: cost, transport, cultural barriers, and lack of services.8

In 2009–10, 446 of 3,100 (7%) of Commonwealth-funded Aboriginal and Torres Strait Islander primary health-care service employees were described as ‘social and emotional wellbeing staff’.9 This group is made up of counsellors, psychologists, and social workers who deliver programs and interventions that aim to improve the social and emotional wellbeing of members of the Aboriginal and Torres Strait Islander community. There is some uncertainty about the effectiveness of many of these programs, and development, funding, and implementation of some programs has been limited by the lack of data to show that they have a positive impact on health outcomes, despite their acceptance by the communities in which they are offered.10 The aim of this paper is to review the empirical evidence that exists to support the delivery of the range of psycho-social interventions that have been implemented to improve SEWB at both the individual and the community level. It does this in a specific way, by utilising the methodology of the systematic review.

Systematic reviews are increasingly seen as providing support for policymakers and managers in that they offer concise summaries to address sharply defined questions, employing rigorous methods to select credible and relevant information to generate summative reports.11,12 They are often preferred to the narrative review, which has been described by McCall and O'Connor (2010)13 as a “subjective exercise in which the author draws conclusions based on an idiosyncratic selection of the literature with no explicit methods of critical appraisal, analysis or summation of data…” and that “are susceptible to biased and misleading conclusions and are best regarded as viewpoints or opinion pieces rather than robust summaries of evidence”. At the same time, systematic reviews have been criticised for focusing too heavily on methodological issues which, in this context, may not be as relevant to the community capacity-building programs that Indigenous communities often focus on.14 In short, in common with other fields in the social sciences, there is no clear consensus as to what constitutes evidence, how it should be gathered and synthesised, or how quality should be appraised.15

Nonetheless, the importance of basing practice guideline recommendations on the systematic identification and synthesis of the best available scientific evidence is a cornerstone of the Government agenda in healthcare16 and, as such, this review seeks to identify the strength of current evidence that is available to support interventions that improve SEWB in Indigenous communities. While this approach will by no means reveal all the programs and interventions that have been implemented in Aboriginal and Torres Strait Islander communities, it does illustrate those most likely to meet the criteria that allow them to be considered to be ‘evidence-based’.

Identification and classification of studies

  1. Top of page
  2. Abstract
  3. Identification and classification of studies
  4. Results
  5. Discussion
  6. References

Studies were identified from a search of the major bibliographic databases (CINCH, PsycINFO, Web of Science, INFORMIT–Indigenous Studies Database and Criminal Justice Abstracts). These databases were selected because they are the key citation sources in the area, covering both Australian and international literature and including high quality abstracts. A set of key search terms, truncated as appropriate and in logically constructed search statements appropriate to each database, was used to guide the searches. Only those items with a publication date from 1992 (following the publication of the Royal Commission into Aboriginal Deaths in Custody) and onwards were included.

Results

  1. Top of page
  2. Abstract
  3. Identification and classification of studies
  4. Results
  5. Discussion
  6. References

The searches identified 8,025 papers that corresponded with the search criteria. (The criteria were: Aborigin* OR Indigen* OR Torres Strait AND Evaluation OR Program OR Intervention OR Diversion OR Outcome OR Impact OR Initiative AND Child neglect OR Child abuse OR Child* OR Young OR Parent* AND Physical OR Sexual OR Emotion* OR Maltreat* OR Substantiat* OR Victim* OR “Self esteem” OR Violen* OR “Cultural strength” OR Remov* OR Protection OR Care OR Services OR Family OR Anxiety OR Depress* OR Wellbeing* OR Trauma OR disorder OR Discriminat* OR Dispossess* OR Psychosis* OR Stress* OR Dislocat* OR Disadvantage OR Trauma OR Grief OR Loss OR “Stolen Generation*” OR “Cultural Identity” OR Healing OR Identity AND Grief OR Loss OR Poverty OR Remote* OR “Physical health” OR Incarcerat* OR “Child removal*” OR Violence OR Abuse OR Land OR Cohesion OR Cultur* OR Spiritual OR Ancestry).

Web of Science (6,644 hits) proved to be the most relevant database. The abstract of each paper was then reviewed, with duplicates and those not of direct relevance to Indigenous communities discarded. This left 72 papers that considered interventions to improve social and emotional wellbeing. Of these, only those that reported the results of evaluations were retained for use in the final analyses. This left 28 publications relating to social and emotional wellbeing. A second set of searches of an additional 25 databases identified 3,148 results and 67 relevant articles, of which eight were included in the final pool.

The identified studies were then screened for quality using the Maryland Scientific Methods Scale,17 a ranking system for research designs according to the strength of internal validity. While this scale has been most widely used in relation to reviewing crime prevention programs, the simplicity of the method makes it particularly suitable for use in other contexts where the aim is to establish the methodological rigour of the available evaluation evidence. Scores on this scale generally reflect the level of confidence that can be placed in an evaluation's conclusions about cause and effect or, in other words, certainty that any observed change (such as reduced substance abuse) is actually caused by a particular program or services. A score of 5 indicates the strongest evidence and a score of 1 considered to be low in scientific rigour. In this system, qualitative studies involving the use of focus groups and interviews are classified as 0, because no firm conclusions about cause and effect can be drawn from them. Three program evaluations were classified as Level 4 or 5. Given the diversity of the programs they evaluate, a brief description of the program content of each of these is provided below. In addition to these programs, those evaluations classified as Level 0,1,2,3 are also listed in Table 1.

Table 1.  Program evaluations.
ProjectAuthorsClassificationMaryland scale rating
Mental Health First Aid: An International Programme for Early InterventionKitchener & Jorm (2007)18Randomised trials, qualitative data, anecdotal evidence.4
Evaluation of the Bringing Them Home and Indigenous Mental Health ProgramsUrbis Keys Young (2007)22Field work, phone interviews submissions, survey, literature review.4
Monitoring the ‘Strong Women, Strong Babies, Strong Culture Program’: The First Eight Years.D'espaignet, Measey, Carnegie & Mackerras (2003)23Quantitative data from hospitals in rates of live births and increased birth weight.4
Family Wellbeing Evaluation ReportTsey, Gibson & Pearson (2006)24Community, unedited video analysis, reflective workshops, analysis of comparable groups), QLD.3
Aboriginal Youth Mental Health Partnership Project Evaluation ReportDobson & Darlin, (2003)25Qualitative/quantitative data, focus groups, interviews (phone) advisory group meetings), urban, SA.2
Breaks in the Road: evaluation of the IYPIPowers & Associates (2003)26Youth, qualitative data, quantitative2
Reconnecting Families Program: training phase evaluation reportVanBeurden, Newell, Hughes, Franks, & Binge (2006)27Aboriginal workers, correlation, urban, NSW.2
Evaluation of an Aboriginal Empowerment ProgramTsey & Every (2000)28Youth, primary, participant observations, urban, NT.1
Central Northern Adelaide Health Service ‘Family and Community Healing Program’Kowanko & Power, (2008)29Community, interviews focus groups, qualitative, data collection, urban, SA.1
Evaluation of Indigenous Hip Hop ProjectsHayward, McAullay, Edwards, Barrow, & Monteiro (2009)30Community, correlation, Urban + rural, WA1
Self-development in Order to Improve Community Development: An Evaluation of a Personal Empowerment Pilot Initiative in Far North Queensland Indigenous communitiesGoo (2003)31Health workers, Primary, Correlation/ Qualitative), QLD, Remote.1
The Purro Birik Social & Emotional Wellbeing Strategy 1999–2000Atkinson & Kerr (2003)32VACCHO member agencies consultations, de-identified data, literature review, VIC1
Evaluation of an Aboriginal Health Promotion Program: A Case Study for KaralundiGrey, Sputore & Walker (1998)33Youth, qualitative and quantitative, WA0
ATSI Family Decision Making Program Evaluation: ‘Approaching Families Together 2002’Rumbalara Aboriginal Cooperative et al. (2003)34Children and youth, qualitative, rural, Vic0
Evaluation of the Murdi Park COAG trialFACHSIA (2006)35Community, qualitative, All0
An Aboriginal Family and Community Healing Program in Metropolitan Adelaide: Description and EvaluationKowanko, Stewart, Power, Fraser, Love, Bromley, 200936Family, victims.0

Program Descriptions

1. Mental Health First Aid: An International Programme for Early Intervention (Kitchener & Jorm, 2008.18–21Classified as: International, Randomised trial, qualitative data, anecdotal evidence. Rated: 5

The program was first developed in 2001, but 600 instructors and 55,000 individuals had been trained in mental health first aid by the end of 2007. The approach was subsequently developed for use with Aboriginal and Torres Strait Islander clients through a process of cultural sensitivity training and expert reference groups, involving the relevant local communities providing comment on the proposed adaptations.

Mental health first aid trains people in early recognition and intervention to reduce the severity of mental illness. The program works on the premise that many people with mental health problems do not seek professional help, and are more likely to do so when it is recommended by someone in their social network. The program is based on the concept of regular first aid and consists of a 12-hour course that teaches participants how to recognise mental illness and understand risk factors. The program encourages participants to develop an ‘action plan’ and each person is given a manual that is available online (http://www.mhfa.com.au). Regular contact between instructors and program participants is maintained through newsletters, contact centres, research updates and a website. The program has been developed to allow participants to then train as facilitators. This option is available online, through private practitioners and through local organisations. A youth-focused program has also been developed, given that most mental illnesses present in this stage of life.

An initial uncontrolled evaluation suggested that program attendance led to an improvement in the recognition of mental disorders, confidence in the value of treatment (to be more like those of health professionals), decreased social distance from people with mental disorders, increased confidence in providing help, and an increase in the amount of help provided to others. Changes were maintained over a six-month follow up. Two subsequent randomised control trials reported statistically significant results on changes in similar measures sustained up to six months after program completion. One trial demonstrated positive effects on mental health. When questioned, most participants (78%) had administered some kind of mental health first aid, and spoke positively of how they had handled the situation – there was no evidence that participants had ‘over reached’ their ability or training. The authors note the difficulties associated with evaluating this type of program, including problems in obtaining information about the recipient of the first aid, as distinct from the person providing first aid. Their studies have relied on qualitative methods to consider this.

2. Evaluation of the Bringing Them Home and Indigenous Mental Health Programs (Wilczynski et al., 2007).22Classified as: Community, field work, phone interviews submissions, survey and literature review. Rated: 4

This evaluation considered four separate programs. The Link-Up Program (formally known as the Access to Effective Family Tracing and Reunion Services Program) provides a national network of services supporting and assisting Aboriginal people affected by past removal policies in tracing their family history and potentially reuniting with their families. The program is culturally specific and has been designed exclusively for Aboriginal clients. The Bringing Them Home Program provides counselling to individuals, families and communities affected by past practices regarding the forced removal of children from Aboriginal families. The Social and Emotional Wellbeing Regional Centre Program funds professional support and training to Link-Up and Bringing Them Home staff as well as to mental health workers. Finally, the Mental Health Program funds Mental Health Service Delivery Projects in Aboriginal Community Controlled Health Services to develop appropriate approaches in mental health service delivery. The evaluation concluded that the programs had provided culturally appropriate services to a large number of Aboriginal clients who were unlikely to have otherwise received services, and that there were generally high levels of client satisfaction and positive outcomes for clients, particularly for the Link-Up and Bringing Them Home programs.

The evaluation of these programs identified a number of factors that had limited their effectiveness. For example, the service was typically used by second and subsequent stolen generations and, as such, missed the primary target group of first generation Stolen Generation members. There was variability in the skills and qualifications of staff, and the use of young counsellors was identified an issue for some older stolen generation clients, which restricted the quality of engagement. Finally, there was a lack of national consistency in service delivery between states, and limited geographical coverage of some programs.

3. Monitoring the ‘Strong Women, Strong Babies, Strong Culture Program’: The First Eight Years (D'espaignet, Measey, Carnegie, & Mackerras, 2003).23Classified as: Community, correlation, NT, rural and remote. Rated: 4

This program began in 1993 as a pilot project in three Top End communities of the Northern Territory, and is a community-based early intervention program that utilises senior Aboriginal women to help younger women prepare for pregnancy and childbirth. The program is based on the philosophy of self-determination and empowerment through building parental capacity. The program was shown to have a positive impact on birth weight by a pre- and post- assessment for an intervention and comparison group using routinely collected data. The authors note that their evaluation design made it difficult to exclude the possibility that concurrent changes in health care provision by the Health Department and other service providers has influenced outcomes, although point to both scientific and logistic reasons as to why randomised control trials are not practical in evaluation programs delivered in sparsely populated remote Aboriginal communities.

Discussion

  1. Top of page
  2. Abstract
  3. Identification and classification of studies
  4. Results
  5. Discussion
  6. References

This paper aimed to systematically review the published research that is currently available to establish the outcomes of those programs and interventions that have the potential to improve social and emotional wellbeing (SEWB) in Indigenous communities. What emerges is that, despite there being a substantial literature on topics that are relevant to SEWB (more than 8,000 papers were identified in the initial searches), only a small number of program evaluations have been published that have involved either Indigenous participants or Indigenous communities. When these are considered in terms of the criteria that are commonly used to define evidence-based practice, the limitations of the current evidence base become very apparent. Thus, what is reported here are some overviews of those programs to illustrate the types of interventions that have been evaluated.

The decision to consider studies in relation to the strength of the evaluation design does, however, place emphasis on only one of several possible evaluation questions: the extent to which it has been established that any changes are a direct result of participation in a program. Other types of evaluation questions are not considered, but are clearly also important. These include those related to: the extent to which communities are consulted; the quality of program implementation; the relevance of the program to local needs; and costs and sustainability. It is worth noting here that as policy makers seek to replicate, generalise, or scale up effective aspects of service delivery, they will need to not only consider the evidence that exists about program outcomes, but also understand how and why particular programs (of which there are many) have been successful. Despite the concern that this small selection of programs might lead to the “biased and misleading conclusions”13 that narrative reviews sometime suffer from, and in the absence of the type of evidence that is required to develop evidence-based practice guidelines, the studies reviewed in this paper do begin to describe the features of programs that have been regarded as successful. Each of the reports identified in these searches make specific comment on a range of issues relevant to the successful implementation of SEWB programs in particular community contexts. The challenge, then, is to distil this information in such a way that a consistent and targeted approach to service development can occur. In the absence of outcome data, this would be a useful first step in defining the role that social and emotional wellbeing workers have to play in closing the gap between Indigenous and non-Indigenous disadvantage.

The diversity of the programs identified in these searches further suggests the need to develop a broader and overarching framework from which to understand low levels of SEWB. The three programs identified as having the strongest level of evidence (according to our criteria) provide mental health first aid, services for those who have been affected by the Stolen Generation, and a program that aims to improve early childhood health. It is difficult to conceptually link these programs in a way that would help articulate how these different types of program each contributes to the wider aim of improving levels of social and emotional wellbeing. The development of logic models, to describe how individual programs and suites of programs directly influence outcomes, would assist in the development of strategy and public policy in this area.

One possibility is to extend and develop the notion of ‘grief and loss’. Grief and loss is a term that encapsulates both the emotional and social aspects of wellbeing, and encompasses psychological distress, life stressors (such as divorce, family illness, death and serious accidents), discrimination, anger, loss of culture, self-harm, and removal from natural family. For example, the legacy of the Stolen Generation is widely acknowledged to have placed a considerable load of grief, loss and unresolved trauma on the Indigenous population, which may be linked to a range of poor psycho-social outcomes.22 Grief and loss therefore represents a holistic, a whole-of-life view that requires an individual to assess all of his or her life, and has clear links with the notion of healing that is referred to in many of the programs described above. Healing can be understood as a spiritual process that includes addictions recovery, therapeutic change and cultural renewal, and involving reclamation of identity.37,38,39 It resonates with the work of Swan and Raphael40 who saw Indigenous health as being grounded in cultural wellbeing, as well as that of Milroy41 who talks about the restoration of harmony and balance, rather than the reduction of symptoms or restoring of function. Although a number of healing programs have been developed,42,43 evidence has yet to be collected that demonstrates their effectiveness, and such programs are often limited in terms of their reach into communities by the availability of trained practitioners. The Link Up and Bringing Them Home programs provide the best examples of those identified in this study of programs that directly address issues of grief and loss.

The construct of grief and loss does, however, offer only one framework from which to develop the logic that underpins current program delivery. Another possibility might include consideration of social determinants of health and how social disadvantage might influence service utilisation. The underlying logic here would articulate how macro factors (such as culture, socio-economic conditions, politics) shape social network factors which, in turn, impact on the psychosocial mechanisms (e.g. social support, social influence, and social engagement) that influence health outcomes.44 Such a logic would appear relevant to understanding the positive outcomes of both the Mental Health First Aid and the Strong Women, Strong Babies, Strong Culture programs described above.

Caruana45 has attempted to document the core characteristics of effective healing programs that have applicability across the range of different programs identified in these searches. They should, for example, be Indigenous owned, designed and evaluated to ensure that they are informed by an Indigenous – not a Western – worldview, and use culturally sensitive screening and assessment tools. They should adopt a holistic and multidisciplinary approach that addresses mental, physical, emotional and spiritual needs through a focus on familial and community interconnectedness as well as connections to the environment and the spiritual realm.46 Cultural renewal should be seen as an essential precursor to healing, with some such as Phillips47 suggesting that “culture is treatment” and programs should be informed by history, and adopt a positive, strength-based approach that recognises and promotes resiliency.

In conclusion, from a public health perspective, the pressing need to implement programs that have a positive impact on low levels of social and emotional well-being in Aboriginal and Torres Strait Islander communities in Australia seems clear. This review represents a first step in bringing together knowledge of what works, in a way that is scientifically defensible and has the potential to inform public policy. What emerges, though, is the conclusion that it is not currently possible to articulate what might be considered evidence-based practice. While there may be legitimate concerns about defining evidence in terms of criteria that are linked directly to quantitative evaluation methodologies, it nonetheless seems clear that progress in this area will continue to be slow if ways to gather robust evidence about program outcomes are not identified. One way of supporting future evaluations may be to return to the question of defining what relevant SEWB outcomes might be, perhaps using grief and loss as a guiding framework. This may allow for the identification of shorter-term markers of improvements in SEWB (such as improvement in dsyphoric or traumatic symptoms, sense of well-being, social participation and engagement) that can be routinely used by evaluators. Changes in these domains, it is suggested, should contribute to the longer-term aim of improving an individual's ability to cope with everyday stressors, work productively, and make positive contributions to the community.

References

  1. Top of page
  2. Abstract
  3. Identification and classification of studies
  4. Results
  5. Discussion
  6. References
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